The Front Lines of Primary Care: The Stories Behind the Crisis (Part I)

In a recent post, Health Beat described the policy strategies that must be employed in order to address the primary care crisis in the United States.  Here, I’d like to focus to the human side of the primary care crunch by highlighting the personal experiences of doctors. Moving from the policy to the personal adds an all-important qualitative element to our understanding of just why American primary care is in such dire straits. 


The Basics

That said, numbers still help set the stage: in 1990, 9 percent of graduating medical students planned to work in primary care/internal medicine; today just 2 percent are choosing primary care. Meanwhile, we know that primary care can help patients avoid expensive, unnecessary medical procedures; obtain regular preventive care; and manage the chronic illnesses that make up between 75 and 80 percent of our $2.3 trillion national health care bill. We can’t afford to run out of PCPs.

The usual reasons cited for the dwindling ranks of PCPs are money and time. Many PCPs make only 1/5 as much as the best-paid specialists. Lower salaries mean that PCPs need to see more patients to have incomes that are comparable to those of their peers. This imperative creates a “hamster wheel” as PCPs frantically cycle through patients who often are suffering from complex, chronic diseases.

No Time to Learn

It’s generally agreed that primary care is unpopular because medical students see the money/time crunch and tell themselves, “no way is that going to be my life.” But the Over My Med Body! blog, which until recently had been maintained by a medical student named Graham, offers a slightly different perspective. According to Graham, students aren’t necessarily mapping out their whole lives when they select a field and apply for residencies—they just want the chance to develop their analytical acumen and grow as doctors. The hamster wheel doesn’t give them that opportunity. 

“In subspecialty outpatient clinics, there’s more time to spend with
patients,” says Graham. “Visits are usually scheduled as 30 minutes
long,” twice as long as the 15-minute standard for primary care visits.
The frenetic pace of primary care makes students a hypertension,
diabetes, hyperlipidemia, peripheral neuropathy, prior MI [myocardial
infarction], stroke, and liver disease (not to mention learning all the
drugs and dosages).” Students and fresh-faced doctors simply can’t get
their bearings; so they abandon the field. 

Of course we like the specialties where we have more time to
figure out all our patients’ problems,” says Graham. Time lets
residents develop their expertise and feel that they can improve as
doctors. As the saying goes, you have to walk before you can run; but
with primary care, you have no choice but to hit the ground running.

Another downside to the hamster wheel is that it provides little
time for doctor-patient interaction. “[W]e got into medicine to help
patients, not just cure their disease,” says Graham. “[Medical
students] prefer to have the time to get to know our patients as
people, not just as the guy with poorly controlled diabetes with
hemoglobin A1C’s in the 10-12 range.” In primary care, they don’t get
that time.

This is heartbreaking to acknowledge. With its professional emphasis
on patient consultation and care coordination, primary care is supposed
to be the most patient-centric field of medicine. But in the eyes of
med students it lacks the very human element that—in theory—should be
at the center of a family doctor’s practice.

“Assembly Line” Medicine

Sadly, many established pros would feel inclined to agree with this assessment. In a 2006 op-ed for the Boston Globe,
an ex-PCP in Massachusetts named Annie Brewster describes how primary
care ended up being far less personal than she had hoped. Initially,
Brewster “chose primary care because [she] love[s] people,” and because
she “wanted to take care of the whole person, body and mind.” But after
a few years of practicing, Brewster was “drowning in this overwhelmed
state,” in which she lost her “ability to take good care of people.”

To keep up with patient visits, Brewster had to “move frantically
from exam room to exam room.” She found it “impossible to know all of
[her patients] well, to give adequate focus to each person’s unique
situation, [and] to sift through the piles of paperwork and lab data
daily.” At one point, Brewster—who had long aspired to be close with
her patients—“walked into an exam room…and introduced [her]self to a
patient. ‘We have met before,’” replied the patient, understandably
annoyed. Brewster was “horrified and saddened” that she had become so
desensitized to her patients. She left primary care and now works as an
urgent care physician.

Like Annie Brewster, Theresa Chan had always loved the idea of being a PCP. According to a recent post
on her blog, Chan entered primary care because of what she calls “the
Dream of Family Practice”—an ideal where “doctors represent the health
of families and the community” and stay with patients “from womb to
tomb,” performing functions that are “fundamental to people’s
well-being.”

But, also like Brewster, Chan saw her “Rockwellian utopia of
medicine” fall apart, albeit for slightly different reasons. One
potentially frustrating reality of primary care is that it’s more
interactive than other types of medicine. As Beverly Woo, a PCP
affiliated with Harvard University, noted in a 2006 commentary for the New England Journal of Medicine,
the scope of primary care often requires sensitive interactions:
“[b]ecause primary care doctors are often the only physicians whom a
patient visits, we must identify problems that are frequently difficult
to talk about, such as alcohol and drug use, domestic violence, and
risky sexual practices,” says Woo. PCPs also have to keep tabs on “how
social factors affect patients who have chronic diseases.” Woo notes
that “[one patient named] Mr. S. had a relapse of alcoholism after
separating from his wife, Ms. R.’s glycated hemoglobin level
skyrocketed when her daughter became ill, and Ms. H. had an
exacerbation of her colitis when she lost both her job and her
housing.” More than any other type of doctor, PCPs have to engage with
the lives of their patients, an often touchy endeavor. When people find
themselves in tough times, even simple discussions can become volatile
and exhausting.

It was this volatility that eventually drove Chan from primary care. Over time, she became fed up with the pushback
she constantly received from patients. They “yelled at the front desk
staff when they had to wait half an hour” and “cussed out our triage
nurses”; patients “stormed out of exam rooms” and threatened “clinic
staff for what most reasonable people would consider minor annoyances.”
Ultimately, Chan spent “a disturbing amount of time managing people’s
expectations and making ‘behavioral contracts’ with” unruly patients in
order to continue providing care. Being a referee and a disciplinarian
“is not what I went into medicine to do,” she says.

While primary care will always maintain a certain amount of
unpredictability, Chan’s experience was made much worse by the volume
of patients she received. Difficult patients are one thing, but dealing
with difficult patients in 15-minute intervals has a cumulative effect:
Chan acknowledges that she would sometimes have to cut short visits
with reasonable, amicable patients in order to deal with the difficult
ones and still maintain her schedule. The sad truth is that the pace of
primary care work leaves little wiggle room, meaning that, when
complications arise, something has to give—even if it’s good, decent
patients who need help.

Ultimately, Chan left primary care and now works as a hospitalist.
Like Graham, who felt that primary care wouldn’t allow him room to
grow, and Annie Brewster, who lost touch with her patients, Chan came
to realize that she wasn’t living up to her aspirations as a doctor.
All three had a similar thought when they observed the realities of
primary care: this is not why I wanted to become a doctor.


Today,
too many PCPs are burning out as they watch their ideals crumble in the
face of the day-to-day realities of their practice. But let’s be clear:
none of this is to say that there’s no hope for primary care on the
whole. In the past, we’ve talked about how to fix the problems, because
they are fixable. But do take these stories seriously; they do more to put the state of primary care into perspective than statistics ever could.

In Part 2 of this post, I’ll talk more about the reality of primary
care—including its upsides—and how we can create a health care system
that nurtures PCPs instead of breaking their spirits.

10 thoughts on “The Front Lines of Primary Care: The Stories Behind the Crisis (Part I)

  1. good post, good stories.
    Primary care attracts those who want to take care of patients as full human beings, focus on their needs, whatever they may be. A big part of doing that well is forming a trusting relationship over time. If you don’t have time to form those relationships due to daily economic realities (the hamster wheel), the job loses a lot of its meaning.
    And satisfaction.
    And effectiveness.
    Getting that back is important if primary care is going to work. Time with patients, spent by the physician, needs to be valued appropriately. That’s the bottom line.

  2. i’m pretty sure the field of medicine is full of specialists with similar complaints who also think ‘this is not why i wanted to become a doctor’.

  3. A Frontline show a number of months back profiled the healthcare system in five different countries including Japan. The PCP from Japan who was interviewed stated that most office visits there last between three and five minutes! Yet, the Japanese have the longest life expectancy in the world. Go figure.
    At a presentation I attended at the University of Pennsylvania last May sponsored by its School of Nursing, one of the panelists who grew up in Copenhagen, Denmark stated that an NP can competently handle up to 85% of all primary care situations and that an NP in the U.S. has as much medical education and training as a PCP in Denmark. I wonder what percentage of PCP office encounters could be easily handled by an NP (or PA) in 15 minutes or less. The physician guild historically vehemently opposed letting NP’s and other mid-levels do more, presumably because they don’t appreciate competition. The AMA’s opposition to retail store clinics staffed by NP’s is only the latest manifestation of this attitude. Yet, we hear the constant complaining about inadequate reimbursements and not enough time to deal with the more complex patients. Perhaps if NP’s and PA’s were allowed to utilize their full potential to serve patients, PCP’s could apply their skills where they are most needed and at a less frenzied pace. Under those circumstances and with somewhat higher reimbursement rates, it might even become a more satisfying and rewarding career again.

  4. Another excellent post about the sad state of primary care in the U.S. I too am one of those ex-primary care physicians that now work as a hospitalist. In my current practice, about 25% of the group are ex-clinic doctors.

  5. Primary Care is also for those who don’t want a 2 year residency, to not have to take call, want to work 9-5 and have no hospital responsibilities, but that is never mentioned when talking salary disparity.

  6. I’m afraid you haven’t closed the loop. And not just you. For any profession to be rewarding there needs to be a satisfaction from the sense of purpose. Maybe docs who go into “Primary Care” so they can have a closer relationship with the patient might be looking for an intimacy paycheck, when our job should be to provide good care. Of course patients scream at us when they expect us to assume responsibility for their health and we drop the ball. We need to be clear about what is our responsibility as primary care docs, and it’s muddy as a swamp.
    The training issue is irrelevant. NP, PA, MD. Alot of what I do (MD) could be done with alot less training. Is that the kind of system we want? I think the primary care docs SHOULD be the smartest, the most emotionally balanced and the most involved. Continuity provides efficiency.
    The real problem with primary care is that the goal, the job description is totally ambiguous. Are we here to please the patient? Customer satisfaction is the goal? Or increase our incomes? Or decrease pathology? And if so, what is the focus, what direction…When family docs could be the foot soldiers in the public health army instead they are small businessmen with no clear product line…No scope, no procedure(unless we get cosmetic lasers)…
    And the only way to make this army of public health is to be able to mine the data. To see what we are doing and what works and what doesn’t. SO…I BELIEVE:
    We could care for this country with alot less docs, spending a lot less money, prescribing alot less medicines, doing alot less procedures…But somehow we will need to invest in data collection, input and communication infrastructure.
    It might not be too hard. Cuba decided it was in the best intersts of their population to immunize for menningococcus. They planned, and immunized the whole Island target population in 6 hours…Paper records, filing cabinets, low tech, lots of people…

  7. ddx:dx
    You wrote: “When family docs could be the foot soldiers in the public health army instead they are small businessmen with no clear product line”
    Very well put.
    And yes, we need the medical evidence and guidelines to give them a much clearer project line.

  8. ddx:dx wrote in part:
    “And the only way to make this army of public health is to be able to mine the data. To see what we are doing and what works and what doesn’t. SO…I BELIEVE:”
    ———
    An overall marvelous post from a societal health improvement mission position. Isn’t it too bad that the profession of public health over all these years has been so hampered and delegated to second rate status by a paranoid organized medicine that was always afraid to allow public health out of the box. What were they so afraid of??

  9. Thanks, everyone.
    Graham—glad you found your way over to Health Beat, and thanks for highlighting those other two posts. It’s very interesting to read an as-it-happens account of a med student considering, and ultimately rejecting, primary care.
    Anonymous—you’re probably right, but there’s something especially sad about that sentiment with regards to primary care, because the motivations for primary care are usually very humane and compassionate—heck, it doesn’t pay well and is stressful…you only do it if you really love the idea of working closely with people who need your help. It’s just a sad thing, when people who want to help others end up feeling as though they’re being punished for their kindness.
    Barry—there is indeed a role for NPs to play. As you know, we’re a little skeptical about the retail clinic model in that it can serve to dilute the consolidation of caregivers that makes the medical home so appealing and useful as an exercise in coordination/teamwork, but there’s definitely a lot of duties that eat up time for PCPs that other folks could do just as well. And they should.
    Ex-idealist—thanks! You’re exactly the group of folks I’m talking about, of course, and exactly who we need to talk to and listen to when redesigning primary care. If you want to understand how to keep people in primary care, you need to understand why ex-PCPs left it—and that’s an interactive exercise, not just an analytical one.
    Ddx—Right on. As I said, a sense of purpose is key. Being a doctor should be a calling, not a paycheck. Sure, we can’t guarantee that everyone who becomes a doctor has a heart of gold, but we should do all we can to structure the practice so that those people feel fulfilled instead of disillusioned.
    And public health is key—health care has become so fragmented and super-specialized, and so focused on narrow silos, that we’ve lost sight of the bigger mission. The medical home is a way to combat against this phenomenon. I tend to think that team-based care would necessarily develop toward a more distinct goal-oriented approach to medicine. A directionless individual can keep on chugging indefinitely, but a team that doesn’t have a clear goal eventually collapses. More interdependence demands greater clarity.
    Also, modernizing health care IT—and data collection, information sharing, etc—is a big part of this, because the best way to manage a team-based practice is a data-driven strategy: with a medical records database, you can stratify patients according to conditions and need so that you can better manage the load (some go to NP, some to the MD, etc, based on the severity of their conditions).